Advanced pediatric airway management is critical for optimized treatment of children. Our long-term goal is to improve patient safety during advanced pediatric airway management. Safe tracheal intubation procedures require sophisticated individual and multidisciplinary team skills that are taught and learned in the pediatric intensive care unit (PICU). Strong preliminary data using the National Emergency Airway Registry (NEAR) specifically adapted for children by our research team demonstrates that intubation success and adverse events are associated with supervised physician trainees who rarely perform this procedure, and their performance is not as safe as identically supervised but experienced sharp end providers. The objective of this proposal is to evaluate the effect of "just-in-time" simulation overtraining on safety and efficacy of advanced airway management. Our Center for Simulation, Advanced Education and Innovation has developed simulation tools that enhance self-efficacy, competence, and team communication. This prospective, interventional study will randomize sharp end providers assigned to manage airway emergencies in the pediatric ICU to either no overtraining versus 20 minutes of either low fidelity or high fidelity simulation overtraining with two specific aims: 1) To evaluate the efficacy of "just-in-time" simulation overtraining; and 2) To evaluate the impact of high versus low fidelity simulation on patient safety outcomes. Both simulated and actual patient tracheal intubations will be evaluated using the NEAR tool, and the primary outcome of tracheal intubation success on first attempt and secondary outcomes of tracheal intubation associated events will be rigorously analyzed by techniques developed and validated by our research team. Relevance to the agency mission: If simulation overtraining of sharp end providers improves actual patient safety, our hospital organization will rapidly implement and track the safety impact of these education tools in practice. Providers, health educators, payers, policy makers, patients, the public and AHRQ would be informed on how to improve the delivery of safe health care across diverse healthcare settings. Safe advanced pediatric airway management requires experienced and trained providers. If this study demonstrates that simulation overtraining improves safety, these techniques will be adopted and implemented in diverse high-risk settings to improve the care of critically ill children. [unreadable] [unreadable] [unreadable]